8:237–250DOI 10.1007/s40506-016-0087-3

Ebola Virus Disease: Issues in Preparedness and Clinical Care (A Hewlett, Section Editor)

Preparing a Hospital for EbolaVirus Disease: a Reviewof Lessons LearnedJonathan D. Grein, MD*

A. Rekha Murthy, MD

Address*Department of Hospital Epidemiology, Division of Infectious Diseases, Cedars-Sinai Medical Center, 8635 W. Third Street, Suite 1150-W, Los Angeles, CA, 90048,USAEmail: Jonathan.Grein@cshs.org

Published online: 1 October 2016* Springer Science+Business Media New York 2016

This article is part of the Topical Collection on Ebola Virus Disease: Issues inPreparedness and Clinical Care

Keywords Ebola I Ebola virus disease I Hospital preparedness I Ebola outbreak I Hospital emergency management IHealthcare worker safety

Opinion Statement

The 2014 Ebola epidemic provided unique insight into how modern hospitals must prepareto handle a disease associated with high transmissibility and mortality. Given the cost andresources required for hospital preparedness, a tiered approach was taken with US hospitalsto facilitate a coordinated response. Effective patient screening at points of entry should beprioritized by all hospitals during an Ebola epidemic. Emphasis should be placed onhealthcare worker training in safety protocols (particularly doffing personal protectiveequipment) and preparing to manage significant volumes of highly infectious waste.Designating an appropriate treatment area, developing a laboratory testing approach,and coordinating a proactive communication strategy are critical elements. Preparing ahospital to care for an ebola virus disease (EVD) patient is a complex effort with multiplelogistical challenges and an iterative process that requires flexibility and ingenuity torespond to a dynamic environment. Despite the many challenges, hospital preparedness forEbola will better prepare us for the next highly communicable disease threat.

Introduction

Ebola virus disease (EVD), along with other hemorrhag-ic fever illnesses, is known for its high mortality rate,propensity to cause explosive outbreaks, and absence ofadequate treatment or vaccines [1, 2]. A very low infec-tious dose, combined with high viral levels and

significant gastrointestinal losses in EVD patients, con-tributes to a high risk of infection to healthcare workers(HCWs) [3]. Hospital-based transmission has played arole in accelerating prior Ebola outbreaks [2]. Prior tothe 2014 West Africa Ebola outbreak, experience with

Curr Treat Options Infect Dis (2016)

clinical management and infection prevention withinmodern healthcare settings was extremely limited [4].Initial guidance from the Centers for Disease Controland Prevention (CDC) reinforced existing protocols fordroplet and contact isolation, as many assumed thatthese precautions would be sufficient in a modern set-ting [5].

The first Ebola case diagnosed in the USA from aWest African traveler, and the subsequent transmis-sion to two direct care providers, was a watershedmoment in US hospital preparation efforts [6, 7••].This incident illustrated the potential for internation-al spread and failure of the initial CDC approach tocontainment and highlighted weaknesses in UShealthcare preparedness. However, subsequent experi-ence in modern hospital settings with revised infec-tion prevention protocols has demonstrated tremen-dous success in both reducing patient mortality andpreventing transmission [3, 8•, 9, 10].

Coupled with this success came challenges,both anticipated and unexpected, as hospitals bal-anced HCW safety with the ability to provide op-timal patient care [3, 10, 11, 12•, 13••, 14•, 15–17, 18•]. Experience in modern settings has dem-onstrated that caring for a patient with EVD is atremendous collaborative effort that requires over-coming many logistical challenges, managing reg-ulatory uncertainties, and addressing HCW anxi-eties, all under intense public scrutiny [3, 10,12•, 14•, 18•]. Biocontainment units such asthose at the University of Nebraska Medical Center[13••], Emory University [3], and the NationalInstitutes of Health [12•] have provided invalu-able insight into elements of successful hospitalpreparedness to care for patients with highly in-fectious diseases. This review is intended to high-light the key lessons learned in hospital prepared-ness for Ebola in modern healthcare settings.

The CDC tiered approach to hospital preparedness

As the 2014 Ebola epidemic progressed, hospitals shifted significant resourcestoward preparing for possible cases. Hospital preparation efforts were costlyand time consuming [19, 20]. Initial frenzied efforts contributed to delays inroutine patient care activities and limited availability of personal protectiveequipment [19, 21, 22].

In an effort to promote a coordinated, networked approach, the CDCreleased guidance for state and local health departments to encourage a tieredapproach to hospital preparation [23]. This guidance outlines three roles forhealthcare facilities, summarized in Table 1: frontline healthcare facilities, Ebolaassessment hospitals, and Ebola treatment centers.

The adoption of this tiered approach facilitated an organized response of theUS healthcare system and helped to mitigate issues such as unnecessary supplystockpiling and diverting unnecessary preparation efforts away from other day-to-day hospital activities [7••]. The USA had identified 55 state Ebola treatmentfacilities [24] as of February 2015, including 10 federally designated regionaltreatment centers as of June 2016 [25].

Coordinating a hospital response

Preparing to manage a patient with Ebola is a complex endeavor thatimpacts a wide range of hospital departments and requires strong lead-ership commitment. Representatives from nursing, infection prevention,disaster preparedness, physicians (particularly critical care and infectiousdiseases), emergency department (ED), materials management, and en-vironmental services are critical [11, 13••, 18•]. Unlike other typical

238 Ebola Virus Disease: Issues in Preparedness and Clinical Care (A Hewlett, Section Editor)

hospital efforts, Ebola preparation raises significant HCW concerns re-garding their own personal safety. Early engagement of communications,

Table 1. The centers for disease control and prevention tiered approach to hospital preparedness for Ebola virus disease

Healthcare facility type Responsibility Key goals of preparationAll facilities Promptly identify, isolate,

and notify public healthofficials of a PUI

• Implement patient screening to promptlyrecognize a PUI

• Develop plans to immediately isolate a PUI andnotify public health officials• Ensure that HCWs are trained in PPE andinfection prevention protocols

Frontline healthcare facilities Promptly identify, isolate, andnotify public health officialsof a PUI

• Prepare to manage a PUI for up to 12–24 h• Prepare to transfer a PUI to an Ebolaassessment/treatment hospital in coordinationwith public health officials

Ebola assessment hospitals Receive and treat a PUI for up to5 days, until EVD is eitherconfirmed or ruled out

• Prepare to receive a PUI from a frontlinehealthcare facility

• Procure adequate PPE and supplies to manage aPUI for up to 5 days• Designate a treatment area• Develop plans to safely manage Ebola waste• Establish laboratory capacity to manage a PUI• Develop protocols for specimen transport for EVDconfirmation• Develop protocols for transport of a confirmed EVDpatient to a treatmentcenter in coordination with public health officials

Ebola treatment centers Receive and treat apatient with confirmedEVD for the durationof illness (may be weeks)

• Prepare to receive a PUI or EVD patient from afrontline healthcare facility or assessmenthospital

• Procure adequate PPE and supplies to manage anEVD patient for weeks• Designate a treatment area• Develop plans to safely manage high volumes ofEbola waste• Establish laboratory capacity to manage an EVD patient• Develop protocols for specimen transport for EVDconfirmation• Ensure availability of trained HCW able to providecare for an extended period of time• Develop and drill to protocols that maximize HCW safety• Develop robust communication strategy for staff,patients, and the public• Develop a behavioral health strategy to manage theemotional health of the EVD patient, including plansand provisions to assist the patient’s family

Source: [23]EVD Ebola virus disease, HCW healthcare worker, PPE personal protective equipment, PUI person under investigation for Ebola virus disease

Preparing a Hospital for Ebola Virus Disease: a Review Grein and Murthy 239

human resources, and behavioral health to address these concerns isindispensable.

Ebola preparation is fraught with logistical challenges across a widevariety of issues [13••, 17, 18•]. A few examples include implementingscreening protocols for suspect cases at points of entry, ED planning forevaluation of persons under investigation (PUI) for EVD, preparation ofa designated treatment area, HCW training in personal protectiveequipment (PPE), procedures for appropriate waste management, andestablishing laboratory protocols. Developing multiple small teams withfocused objectives and administrative oversight can facilitate a coordi-nated approach. In the setting of an Ebola epidemic, the importance offrequent and transparent communications to hospital staff to providecurrent situation updates and preparation efforts cannot be overstated.

Existing Hospital Incident Command Systems (HICS) can be utilizedin the event of a suspect of confirmed EVD patient [13••, 18•, 26]. Thisapproach has shown to be effective in managing other disaster events,such as severe acute respiratory syndrome [27–29].

The importance of close collaboration with public health authoritiesto coordinate a response to a suspect or confirmed EVD patient shouldbe emphasized [13••]. Public health officials will play a key role incoordinating patient transport, confirmation testing, HCW temperatureand symptom monitoring, and media communications. Engaging rele-vant local and state health officials in hospital preparation efforts willallow for a more effective response.

Access points and early detection

The circumstances surrounding the first patient to be diagnosed on USsoil highlighted the importance (and challenges) of effective screeningand early isolation of a PUI [6, 7••]. Hospitals should develop tools forfrontline staff to screen patients at points of entry and centralize noti-fication of suspect cases to facilitate a consistent and appropriate re-sponse. Signage for patients and visitors at entry points can reinforcescreening methods. Electronic medical records can be modified to pro-mote a consistent screening process, although should not be relied uponexclusively [30–32]. It is important to remember that exposure criteriaand screening protocols may change rapidly as the outbreak evolves.

Education of frontline staff regarding EVD risk factors, symptoms,and modes of transmission can help to allay anxiety. Specifically, it maybe helpful to remind staff that EVD infectiousness requires direct contactwith patient excretions and that patients are much less infectious duringthe early stages of illness, when viral loads are lower and excretions areminimal [33]. This point is reinforced by the first case diagnosed in theUSA, when the patient’s initial encounter with hospital staff resulted inno transmission despite lack of isolation [6, 7••].

The ED is understandably an area of significant focus for Ebolascreening, initial isolation, and management. Guidance on ED Ebolapreparedness is available [18•, 34–36]. Hospitals should not neglectscreening at all other points of entry in the hospital. Developing a

240 Ebola Virus Disease: Issues in Preparedness and Clinical Care (A Hewlett, Section Editor)

consistent screening tool and clear response plan for all entry points(urgent care, outpatient clinics, and physician offices) can mitigatefrontline HCW anxieties during an Ebola outbreak.

Healthcare worker teams

Safely caring for a patient with EVD requires utilizing PPE and adoption ofinfection prevention protocols that are not routinely practiced during routinepatient care activities. The logistics ofmaintaining competency in these skills fora large number of HCWs can quickly become overwhelming. Thus, manyhospitals have developed smaller response teams that may be activated asneeded.

Both volunteer and universal models for HCW training can be considered[12•], though it is important to note that a significant number of HCWs mayrefuse to care for an EVD patient (25 % in one survey) [37, 38]. Direct careproviders may develop significant concerns regarding their personal safety,safety of their family, and fears of quarantine. For these reasons, many hospitalshave elected to utilize volunteer staff that agrees to care for EVD patients [12•,14•]. Some hospitals may choose to restrict certain HCWs from participating inthe care of an EVD patient, such as pregnant women, those withimmunocompromising conditions, impaired skin integrity, or claustrophobia[17]. Views on the role of trainees in direct patient care are variable [10, 13••,22].

The staffing of an EVD care team is specific to each hospital setting. How-ever, given the expected acuity of EVD illness, limited time that can be spent inPPE (no more than 4 h), and other logistic challenges (such as doffing assis-tance and managing the high volume of waste), staffing ratios are significantlyhigher that typical care settings [7••, 13••]. It is essential to incorporate the roleof the trained observer, site manager, and doffing assistant into staffing plans tomaximize optimal infection prevention practices [39]. Treatment centers mustanticipate that an EVD patient may require 2 weeks or more of care [8•]. Teamstaffing should be adequate to prevent HCW fatigue over such a prolonged andintense hospitalization.

Incorporating HCWs with broad skill sets (such as critical care nurses withhemodialysis experience) can reduce the number of HCW required to directlycare for the patient. Additionally, roles traditionally provided by ancillaryhospital staff, such as daily environmental cleaning, food delivery, and imaging,should be delegated to physicians or nurses providing direct patient care, whichmay require additional training. Use of remote telemedicine tools should beused whenever possible to reduce unnecessary exposures.

Given the high rate of respiratory and renal failure associated with EVD,HCW teams must prepare to handle procedures such as intubation, central lineplacement, and continuous renal replacement therapy [8•, 13••, 14•]. For thesereasons, the roles of critical care-trained physicians and nurses are paramount.Other specialties, such as infectious disease and nephrology, are also critical inthe management of EVD patients; however, these roles may be managedremotely (utilizing telemedicine approaches) in many instances.

During the 2014 Ebola epidemic, public health protocols required activesurveillance of all HCWs who cared for EVD patients for 21 days following their

Preparing a Hospital for Ebola Virus Disease: a Review Grein and Murthy 241

last encounter, even if no breaches in infection prevention practices wereidentified [12•]. The logistical challenges of this screening and communicationof results to public health authorities can be burdensome; developing electronictools to facilitate this twice-daily screening may minimize this. Decisions torestrict the activities of the EVD care team from other patient care activities arecontroversial but may be considered to mitigate patient and community anxi-ety. Human resources and any relevant employee unions should also beconsulted as appropriate to develop institution-specific protocols around workrestrictions or additional pay [18•].

Lastly, it is important to consider the psychological impact that caring for apatient with EVD may have on the care team. Integrating behavioral healthspecialists into the team can be critical to the success of the team during such anintense time [13••]. Hospitals should consider providing temporary housingfor the EVD care team, as some HCWs may fear exposing or stigmatizinghousehold contacts [37]. Additionally, providing personal items (such as shoesand undergarments) for use by HCW while providing patient care can helpmitigate their concerns about bringing anything home that entered the patients’room.

Training and drills

Self-contamination of skin or clothing is common during PPE doffing and canbe improved with repeated training [40–42]. PPE required for EVD patients issignificantly more complex than PPE used for typical care, and even unnoticedbreaches in PPE can result in Ebola transmission [6]. Additionally, the level ofPPE required can impede dexterity and field of view that may impair theirability to perform routine procedures such as placing vascular access [10, 39].For these reasons, HCWs caring for EVD patients should undergo rigorous andrepeated training in PPE that incorporates verification of competency in don-ning and doffing of PPE, as well as practice with relevant procedures in PPE[39].

PPE training protocols which incorporate the use of a specialist readingaloud each step and providing immediate feedback are more effective thanmore conventional trainingmethods [41]. Use of fluorescent lotions can also bea useful educational tool and provide immediate feedback [42], and videosurveillance with feedback can reduce error rates [43]. Importantly, althoughrepeated training can significantly reduce the rate of breaches, the error rate doesnot decrease to zero [41, 42]. Additionally, contamination may occur in up to30 % of instances when no lapses in technique were observed [42]. For thesereasons, a key element of the revised CDC guidance was incorporation of adoffing assistant and trained observer to the PPE doffing process, which shouldoccur in a dedicated areawith ample space [39]. These roles should be staffed byteam members who are familiar with the PPE and infection prevention proto-cols.

Drills are extremely useful to assess current readiness and expose gaps inplanning. Scenarios should reflect realistic scenarios that incorporate all HCWcategories that may be impacted by the care of an EVD patient. No-notice drillscan also assess the effectiveness of screening processes as well as availability ofthe EVD response team [44]. Debriefing and after-action reports are an essential

242 Ebola Virus Disease: Issues in Preparedness and Clinical Care (A Hewlett, Section Editor)

component to review lessons learned and should involve all relevant partici-pants.

Personal protective equipment

Given the significant gastrointestinal excretions expected during the clinicalcourse of EVD, HCWs must have all skin, clothing, and mucous membranescovered with fluid-impermeable PPE. Fluid-impermeable material that meetsANSI/AAMI PB70 level 4 requirements (gowns) or ASTM F1671 or ISO 16604≥14 kPa (coveralls) is recommended [39]. Less extensive PPE requirements maybe considered for suspect cases (PUI) without vomiting, diarrhea, or bleeding[45].

Variability in PPE design and lack of standardizationmean that detailed PPEdonning and doffing protocols will vary by facility. During an outbreak, hos-pitals must prepare for supply shortages that may affect which PPE is available[11, 22]. Additionally, hospitals should assess the volume of PPE suppliesrequired based on their status (frontline, assessment, or treatment center); toolsto assist with estimating PPE needs are available online [46]. Adequate PPE forothers, such as the trained observer, doffing assistant, and laboratory techni-cians, should be considered during planning.

Data regarding the optimal PPE types and doffing protocols for highlyinfectious diseases remains scant and of very low quality, as recently reviewedby others [47, 48]. That being said, detailed donning and doffing protocols areavailable online from the CDC [39] and other institutions [49]. Differentprotocols have been successfully used, and high-quality evidence in favor of asingle approach does not exist. Adding additional PPE layers to recommendedprotocols may lead to negative unintended consequences and should be care-fully evaluated.

There has been significant debate about the need for respirators while caringfor EVD patients. Although there is no evidence for airborne transmission ofEbola [40, 50], theoretical concerns exist around the possibility of aerosoliza-tion during certain procedures such as intubation, which may occur unexpect-edly [39]. For these reasons, respirators are routinely recommended. A poweredair purifying respirator (PAPR)may providemore comfort during extended carethan a N95 respirator, although factors such as weight and PAPR reprocessingmust be considered.

Finally, hospitals should ensure that PPE is stored appropriately and readilyaccessible and consider routine inventory and quality checks to verify thatadequate PPE supplies remain intact.

Treatment care areas

Patients with EVD should be cared for in a single patient room with privatebathroom, with textiles removed prior to patient arrival [51]. Given the likeli-hood of performing aerosol-generating procedures (i.e., intubation), negative-pressure isolation rooms are recommended [51]. Rooms designed to provideintensive care unit level of care are highly recommended [9, 10]. Once a suspect

Preparing a Hospital for Ebola Virus Disease: a Review Grein and Murthy 243

or confirmed EVD patient is admitted, all efforts should be made to preventsubsequent patient transport outside the room. Thus, direct admission to anexisting ICU bed should be strongly considered, even for PUIs with mildsymptoms.

Room size is a significant factor to consider when selecting an EVD treat-ment area. Medical equipment will likely remain in the room until patientdischarge given the need to perform adequate terminal disinfection. Thus,rooms should have adequate size to store dialysis equipment, ventilators, andportable imaging equipment such as ultrasound. Many hospitals planned toconduct point-of-care testing within the patient room to minimize specimentransport outside the room, which requires additional space [12•, 14•, 22, 52].

The space immediately outside the treatment room should provide ade-quate space for doffing, which includes the presence of a trained observer andpossibly a doffing assistant [39]. Additionally, extensive space for PPE and othersupplies may be required and in near proximity to the treatment area [10]. IfPAPRs are used, space should be designated for reprocessing [7••, 18•]. Finally,maintaining secured access to the treatment area is important to protect HCWsafety and patient privacy. Experience with creating a treatment area in theabsence of an existing biocontainment unit has been published [7••, 16, 18•],and lessons from the design of existing biocontainment units can be instructive[3, 12•, 13••, 14•, 17, 53].

Waste management

Caring for an EVD patient generates tremendous volumes of waste that must beaddressed proactively [3, 12•, 14•, 54]. Experience inUS settings describes up to40 Blarge bags^ per day of solid waste, up to 10 l a day of fluid [3], and over1000 lb of waste during a 3-week period [13••]. In addition to PPE, linens andother items within the patient room will be autoclaved and discarded, con-tributing to the significant waste stream. Existing onsite autoclaves, if present,may be overwhelmed during the course of EVD care if not of sufficient capacity[12•].

Hospitals may either sterilize waste onsite or contract with commercialvendors to transport waste offsite [54]. Since Ebola-contaminated waste gener-ated during patient care is categorized as category A by the US Department ofTransportation, special permits and strict transportation requirements apply[14•, 55]. Onsite autoclaves circumvent the need for this costly option, assterilized Ebola waste can be managed as regular medical waste [55]. However,a survey of Ebola treatment centers identified that only 23 % have the capacityfor onsite waste sterilization [20]. Installing autoclaves within the treatmentunit is ideal, as it can mitigate the need to transport waste through the hospital[54]. Of note, US experience illustrates that it may be challenging to find adestination willing to accept Ebola-generated waste, even if it has been appro-priately sterilized [12•].

Local regulationsmay require special handling of liquid waste prior to disposalin the sewer system, despite the lack of evidence that Ebola can be transmitted thisway [56]. Biocontainment units at the NIH [12•], Emory [3], and Nebraska [13••,

244 Ebola Virus Disease: Issues in Preparedness and Clinical Care (A Hewlett, Section Editor)

14•, 54] performed pretreatment of liquid waste with a disinfectant, such asquaternary ammonium compound with 10-min dwell time [12•]. All effortsshould be made to minimize splashes when pretreating liquid waste.

Laboratory considerations

Although testing should be kept to a minimum to reduce HCW exposure risk,patients with EVD require close monitoring of serum electrolytes and renalfunction for optimal care [6, 8•, 10]. Additionally, cell counts, coagulationstudies, and liver function tests aid in clinical management, and results ofmalaria screening, blood cultures, and influenza testing can impact treatmentstrategies [52]. Hospital laboratories can safely perform these tests if appropri-ate risk mitigation steps are taken [57]; however, abundance of caution has ledmany hospitals to restrict testing to point of care within the patients’ room or anearby dedicated biosafety hood.

Most Ebola treatment centers (87 %) plan to have point-of-care (POC)testing available within the patients’ room [52], which eliminates risk of ex-posing laboratory technicians and provides timely results. POC testing appearsreliable compared to traditional testing methods in critically ill patients [58].However, this approach is only available for selected tests, adds additionalresponsibilities to direct care providers, and requires extra training. Most Ebolatreatment centers also have lab support from their clinical and public health lab,and nearly all had access to a biosafety level 3 lab [52].

Confirmatory Ebola testing requires coordination with public health au-thorities and is only performed at selected labs. This requires category A spec-imen packaging prior to transport, whichmust be performed by personnel whohave received specific training. Serial measurements of Ebola serum viral levelsmay have prognostic value andmay be requested by health officials during careof an EVD patient [59].

Communications

The 2014 Ebola epidemic created a sense of fear among HCWs and the com-munity reminiscent of the early acquired immunodeficiency syndrome (AIDS)epidemic. Public misinformation may contribute to popular support for quar-antines, travel bans, and behavioral changes such as avoiding public transport[60]. As many as 25 % of HCWs may refuse to provide care to an EVD patient,with concerns over exposing loved ones overshadowing concerns over personalsafety [37]. The value of a coordinated communication strategy to mitigatethese concerns should not be underestimated.

An effective communication strategy should begin early in hospital plan-ning. During an epidemic, communications should be developed targetinghospital staff, patients, and visitors, as well as external media. Hospitals shouldstrive for providing a consistent message that provides Ebola education, reflectstransparency in preparation efforts, emphasizes safety, and acknowledges un-certainty [3, 61]. Flexibility to respond to rapidly changing circumstances is

Preparing a Hospital for Ebola Virus Disease: a Review Grein and Murthy 245

essential [62]. Proactively engaging the public media should be considered toeducate and inspire confidence in hospital preparations.

During the treatment of a suspect or confirmed EVD patient, media atten-tion can be intense and unwelcomed [12•]. Appointing a designated spokes-person to provide consistent and frequent updates should be strongly consid-ered, and coordinating external communications with public health officialsand experts can foster credibility [62]. Frequent and transparent communica-tions to staff with situational updates that also emphasize the need for patientprivacy are important [3]. Including staff and the patient’s family in updatesprior to media release can foster confidence in the hospital response. Addi-tionally, hospitals have successfully utilized social media outlets to providebrief, frequent updates [3, 62].

The patient

As the focus of much energy is understandably targeted on HCW safety duringhospital Ebola preparations, it is important to remember to consider themedical and emotional well-being of the patient. Nearly all PUIs evaluated forEVD in the USA did not have Ebola, though many had other life-threateningillness such as malaria [63]. Isolation protocols can contribute to delays inappropriate diagnostic evaluation and treatment. When EVD is diagnosed,widespread publicity endangers patient confidentiality; efforts to protect patientprivacy (such as preventing unwarranted access to electronic medical records)should be emphasized. From a patient’s perspective, the psychological burdenof undergoing prolonged isolation with an EVD diagnosis must be immense.Safe means of family communication (direct visualization through windows orelectronic audio-visual methods), as well as activities to promote physicalrehabilitation while awaiting clearance of viremia during recovery, should beprovided.

Other considerations

Many other issues warrant consideration and planning. Having a mechanismfor rapid approval of experimental therapies through the institutional reviewboard is essential. Given the high risk of renal failure seen with EVD, planningfor renal replacement therapy should be prioritized [64], with guidance fromthe CDC and the American Society of Nephrology available [65, 66]. EVDpatient may require intubation or central line placement, so protocols forimaging should also be prioritized. Use of bedside ultrasound is appealinggiven its wide variety of uses and small footprint within the room compared toportable X-ray [67]. Protocols for using portable X-ray within the patient room,as well as disinfection of imaging equipment, should be developed [18•, 68].Transport for CT and MRI studies is generally not considered in a patient withconfirmed EVD, though decisions for PUIs with less severe illness are morechallenging.

Developing plans for the care of a pregnant or pediatric EVD patient is aparticularly challenging endeavor that has received significant attention [69–72]. The approach to a suspect or confirmed EVD patient that requires surgery ishighly controversial, though proposed guidance has been published [73].

246 Ebola Virus Disease: Issues in Preparedness and Clinical Care (A Hewlett, Section Editor)

Lastly, ethical decisions about clinical management including use of cardio-pulmonary resuscitation should be discussed in consultation with bioethicsexperts and clinicians in advance to establish a consensus approach.

Conclusion

Preparing a hospital to care for an EVD patient is a complex effort that requiressignificant leadership commitment to overcome multiple logistical challenges.It is also an iterative process that requires flexibility and ingenuity to respond toa dynamic environment. Preparedness efforts must engage leaders from keyareas, including nursing, physicians, infection prevention, disaster manage-ment, administration, laboratory, communications, ED, and environmentalservices (to name a few). Major objectives include maintaining a trainedHCW team; identifying and preparing a dedicated treatment area; selectingand storing appropriate PPE and other supplies; developing protocols thatmaximize HCW safety; planning for safe handling and disposal of high-volume waste; and communicating proactively with staff, patients, and thecommunity. Although the challenges aremany, hospital preparedness for Ebolawill better prepare us for the next emerging highly communicable diseasethreat.

Compliance with Ethical Standards

Conflict of InterestDr. Jonathan D. Grein declares that he has no conflict of interest.Dr. A. Rekha Murthy declares that she has no conflict of interest.

Human and Animal Rights and Informed ConsentThis article does not contain any studies with human or animal subjects performed by any of the authors.

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